The Hospital Anxiety and Depression Scale (HADS)

Each item is rated on a four-point scale, giving maximum scores of 21 for anxiety and depression. Scores of 11 or more on either subscale are ... Skiptomaincontent Advertisement SearchallBMCarticles Search TheHospitalAnxietyandDepressionScale(HADS):translationandvalidationstudyoftheIranianversion DownloadPDF DownloadPDF Research OpenAccess Published:28April2003 TheHospitalAnxietyandDepressionScale(HADS):translationandvalidationstudyoftheIranianversion AliMontazeri1,2,MariamVahdaninia1,MandanaEbrahimi2&…SoghraJarvandi2 Showauthors HealthandQualityofLifeOutcomes volume 1,Article number: 14(2003) Citethisarticle 78kAccesses 290Citations 3Altmetric Metricsdetails AbstractBackgroundTheHospitalAnxietyandDepressionScale(HADS)isawidelyusedinstrumenttomeasurepsychologicalmorbidityincancerpatients.ThisstudyaimedtotranslateandtestthereliabilityandvalidityoftheIranianversionoftheHADS.MethodsTheEnglishlanguageversionoftheHADSwastranslatedintoPersian(Iranianlanguage)andwasusedinthisstudy.Thequestionnairewasadministeredtoaconsecutivesampleof167breastcancerpatientsandstatisticalanalysiswasperformedtotestthereliabilityandvalidityoftheHADS.ResultsIngeneraltheIranianversionoftheHADSwasfoundtobeacceptabletoalmostallpatients(99%).Cronbach'salphacoefficient(totestreliability)hasbeenfoundtobe0.78fortheHADSanxietysub-scaleand0.86fortheHADSdepressionsub-scale.Validityasperformedusingknowngroupscomparisonanalysisshowedsatisfactoryresults.Bothanxietyanddepressionsub-scalesdiscriminatedwellbetweensub-groupsofpatientsdifferinginclinicalstatusasdefinedbytheirdiseasestage.ConclusionThispreliminaryvalidationstudyoftheIranianversionoftheHADSprovedthatitisanacceptable,areliableandvalidmeasureofpsychologicaldistressamongcancerpatients. BackgroundTheHospitalAnxietyandDepressionScale(HADS)isabriefandwidelyusedinstrumenttomeasurepsychologicaldistressincancerpatientsanditisavailableinmanylanguagesforexampleFrench,German,Dutch,Italian,Spanish,Chinese,andArabic.IthasbeenshownthattheHADSgivesclinicallymeaningfulresultsasapsychologicalscreeningtool,inclinicalgroupcomparisonsandinstudieswithseveralaspectsofdiseaseandqualityoflife.Itissensitivetochangebothduringthecourseofdiseaseandinresponsetomedicalandpsychologicalinterventions[1].ArecentreviewoftheliteratureonthevalidityoftheHADSclearlyindicatesthatitisawell-performedquestionnaireinassessingthesymptomseverityandcasenessofanxietydisordersanddepressioninbothsomatic,psychiatricandprimarycarepatientsandeveninthegeneralpopulation.TheHADSisapopularinstrumentamongresearchersfromdifferentnationsanditisestimatedthatsince1996to2002thenumberofHADSpapers'thathavebeenpublishedhasincreasedalmostfourfold[2].TheaimofthisstudywastotranslatetheHADStoPersian(Iranianlanguage),validateandusethequestionnaireinstudiesofqualityoflifeincancerpatientsinIran.CurrentlythereisnosuchquestionnaireavailableinIran.MethodsTranslationThe'forward-backward'procedurewasappliedtotranslatetheHADSfromEnglishintoPersian(Iranianlanguage).TwogeneralpractitionerstranslatedthequestionnaireintoPersianandthesewerebackwardtranslatedintoEnglishbyahealthprofessionalandaprofessionaltranslator.Then,aprovisionalversionoftheIranianquestionnairewasprovided.Thereweresomeproblematictermssuchas'woundup','butterfliesinthestomach'and'sloweddown'whichwereculturallyadaptedandafteraconsensusbyallauthorsthefinalversionwasdeveloped.Patients,datacollectionandstatisticalanalysisThefinaldraftoftheIranianversionwasadministeredtoasampleofnewlydiagnosedbreastcancerpatientsattendingthebreastclinicofalargeteachinghospitalinTehran,Iran.Therewerenorestrictionsonpatientselectionwithregardtohistologictypeofbreastcancer,ageorothercharacteristics.Atrainedfemalenurseduringonecompletecalendaryearcollectedthedatainface-to-faceinterviews.Thestudydesignandthemethodofdatacollectionarefullyexplainedelsewhere[3].However,totestreliabilitytheinternalconsistencyofthequestionnairewasmeasuredusingCronbach'salphacoefficientandalphaequaltoorgreaterthan0.70wasconsideredsatisfactory.Validityoftheinstrumentwasperformedusingtheknown-groupscomparisonandconvergentanalysis[4].Knowngroupscomparisonanalysiswasexaminedtotesthowwellthequestionnairediscriminatesbetweensub-groupsofpatientswhodifferedinclinicalstatusasdefinedbytheirdiseasestage.Convergentvaliditywasassessedusingthecorrelationofeachitemwithitshypothesizedscale.ThePearsonproductmomentstatistic(Pearson'scorrelationcoefficient)of0.40orabovewasconsideredsatisfactory.FurtheranalysiswascarriedouttodemonstratetheextenttowhichtheHADScorrelateswithtwosubscalesderivedfromthevalidatedIranianversionoftheEuropeanOrganizationforResearchandTreatmentofCancerQualityofLifeQuestionnaire(EORTCQLQ-C30)[5].Itwasexpectedthattheanxietyandthedepressionsubscalewouldcorrelatenegativelywiththesemeasures(emotionalfunctioningandglobalqualityoflifesubscales).Inadditioninter-correlationbetweenanxietyanddepressionsubscaleswascalculatedusingPearson'scorrelationcoefficient.QuestionnairesTheHADScontains14itemsandconsistsoftwosubscales:anxietyanddepression.Eachitemisratedonafour-pointscale,givingmaximumscoresof21foranxietyanddepression.Scoresof11ormoreoneithersubscaleareconsideredtobeasignificant'case'ofpsychologicalmorbidity,whilescoresof8–10represents'borderline'and0–7'normal'[6].EmotionalfunctioningandglobalqualityoflifewasmeasuredusingtheEORTCQLQ-C30subscales.Emotionalfunctioningcontains4itemsandeachitemisratedonafour-pointscaleandglobalqualityoflifecontains2itemsandeachitemisratedonaseven-pointscale.Alineartransformationwasperformedtostandardizetherowscores.Scoresofeachsubscalesrangefrom0to100andthehighervaluesindicateahigher(better)leveloffunctioningandglobalqualityoflife[7].Demographicdatawerecollectedusingashortquestionnaireatthepatients'firstclinicvisitandincludedrecordingofage,educationallevel,andmaritalstatus.Diseasestagewasextractedfromcaserecords.ResultsThecharacteristicsofthebreastcancerpatientsandtheirscoresontheHADSareshowninTable1.Themeanagewas47.2(SD=13.5)years,mostweremarried(68%),andhadcompletedprimaryorsecondaryeducation(66%),andhadloco-regionaldisease(45%).Almostallpatients(99%)foundtheIranianversionoftheHADSacceptable.Themeananxietyscorewas10.6(SD=4.1)whereasthisfordepressionwas6.2(SD=4.5).Table1ThecharacteristicsofthebreastcancerpatientsandtheirscoresontheHADS(n=167)Fullsizetable TheinternalconsistencyoftheHADSasmeasuredbytheCronbach'salphacoefficienthasbeenfoundtobe0.78fortheanxietysubscaleand0.86forthedepressionsubscaleindicatingasatisfactoryreliability.ValidityoftheHADSwasexaminedusingtheknowngroupscomparisonandconvergentanalysis.TheHADSwelldiscriminatedbetweensub-groupsofpatientsasdefinedbytheirdiseasestageindicatingthatanxietyanddepressionscoresweresignificantlyhigherinpatientswithadvanceddisease(P<0.0001onbothsubscales).TheresultsareshowninTable2.ConvergentvaliditywasassessedusingthecorrelationofeachitemwithitshypothesizedscaleandtheresultsshowedthatthePearson'scorrelationcoefficientvariedfromthe0.47to0.83foranxietysubscaleandfrom0.48to0.86fordepressionsubscale,andallwerestatisticallysignificant(P<0.0001).However,item7(Icansitateaseandfeelrelaxed)anditem11(IfeelrestlessifIhavetobeonthemove)showedaweakercorrelationwithanxietyscore(r=0.47and0.50respectively)anditem10(Ihavelostinterestinmyappearance)showedaweakercorrelationwithdepressionscore(r=0.48).Furthermore,whenthecorrelationbetweentheHADSsubscalesandemotionalfunctioningandglobalqualityoflife(subscalesoftheEORTCQLQ-C30)wasinvestigated,asexpectedasignificantnegativecorrelationemerged.Inadditiontherewasasignificantinter-correlationbetweenanxietyanddepressionsubscalesascalculatedbyPearson'scorrelationcoefficient(r=0.72,P<0.0001).TheresultsareshowninTable3.Table2Breastcancerpatients'scoresontheHADSanxietyanddepressionsubscalesbydiseasestage(n=167)Fullsizetable Table3CorrelationofHADSitemswithitshypothesizedsubscales,overallHADS;andHADSsubscalesandoverallHADSwithemotionalfunctioningandglobalqualityoflifescoresFullsizetable DiscussionThiswasavalidationstudyofoneofthemostwidelyusedinstrumentstomeasureanxietyanddepressionincancerpatients.TheIranianversionoftheHADSprovedtobeacceptabletopatientsanditisworthnotingthatthequestionnairewasadministeredbyatrainednurseinface-to-faceinterviews,althoughtheoriginalquestionnaireisaself-ratinginstrument.Thiswasduetothefactthattherewerearelativelyconsiderableproportionofilliteratepatientsinthestudy.Itisarguedthatface-to-faceinterviewsmayleadtosocialdesirabilitybiasparticularlyinsensitiveareassuchasassessmentofmentalhealth[8].Wedonotknowmodeofadministrationthroughinterviewshowmuchaffectedtheresults.However,patientsindicatedthatsomequestionsweredifficulttoanswer,especiallyitems10and11.Perhapsthiswasthereasonwhyaweakercorrelationwasfoundfortheseitemswiththeircorrespondingsubscale.Itseemsthatweakercorrelationofitems10and11wouldalsobeduetosomeproblemsoftranslationthatmightnotbereachedcross-culturalcomparabilitywiththeoriginalversionofthequestionnaire.SimilartomoststudiesreliabilityoftheIranianversionoftheHADSasmeasuredbytheinternalconsistencyoftheanxietyandthedepressionsubscaleswasfoundtobesatisfactory.However,therewasastrongcorrelationbetweenanxietyanddepressionsubscales.Onemayarguethatthisisevidencetosuggestthattheinstrumentisageneralmeasureofdistressratherthanameasureofanxietyanddepression.InotherwordsitispossibletosuggestthatbecauseofthehighcorrelationbetweenthetwoHADSsubscalesitcanbeusedasanunidimensionalscalewithaglobalscoreforthewholeinstrument(Table3).ArecentstudyinbreastcancerpatientsconcludedthatthetotalscoreoftheHADSisavalidmeasureofemotionaldistressanditcanbeusedasascreeningquestionnaireforpsychiatricdisorders.Thesamestudyindicatedthattheuseofthetwosubscalesasa'caseidentifiers'orasanoutcomemeasureshouldbeconsideredwithcaution[9].Incontrast,apartfromfindingsfromseveralstudiesthatshowedtheHADSisatwo-factorinstrument[10],ithasbeensuggestedthatinter-correlationbetweentheanxietyandthedepressionsubscalesisnotsurprisingsincethisismainlyduetoarealcoincidenceofanxiousanddepressedsymptomsandonlytoalesserextenttoinadequaciesoftheinstrument[1].TheknowngroupscomparisonanalysisindicatedthattheIranianversionoftheHADSisavalidinstrumentformeasuringanxietyanddepressioninbreastcancerpatientssincetheinstrumentwasabletodiscriminatebetweenpatientswhowereclinicallydifferent.However,thestrikingfindingfromthispreliminaryvalidationstudywasthatIranianwomenwithbreastcancershowedahigherlevelofanxietyandarelativelylowerlevelofdepression.Thismayreflectthefactthatthecut-offscorewouldbedifferentinIraniancancerpatientssofurtherinvestigationmightbenecessary.Indeedthesensitivityanalysisusinganobjectivecriteriaoragoldstandardtestisneededtoanswerthisquestion.Unfortunatelythepresentstudywaslimitedinthisrespect.AsfarasassessmentofanxietyanddepressioninbreastcancerpatientsisconcernedstudieshaveshownthattheHADSmayresultinunderestimationofpsychiatricmorbidityamongwomenwithearlystagebreastcancerandthereforeitsutilityforscreeningpurposesinearlystagebreastcancerpatientsislimited[11,12].Incontrast,mostoftheexitingliteraturesuggeststhattheHADSisasuitableinstrumentformeasuringanxietyanddepressioninbreastcancerpatients[13,14].TheHADSanxietyanddepressionscoresshowedanegativebutsignificantcorrelationwithemotionalfunctioningandglobalqualityoflifeaswasexpected.Thismeansthatthosewhoweremoreanxiousordepressedshowedlowerlevelsofemotionalfunctioningandglobalqualityoflife.ThusthiscouldberegardedasadditionalevidencetosuggesttheHADSisavalidquestionnaire.InafewvalidationstudiesusuallyconcurrentvalidityanalysiswasappliedusingthecorrelationbetweentheHADSandtheBeck'sDepressionInventory(BDI),ortheGeneralHealthQuestionnaire(GHQ),ortheState-TraitAnxietyInventory(SATI)[15–17].However,sincetherewasnoanIranianversionofthesequestionnairesweusedtwosubscalesfromthevalidatedIranianversionoftheEORTCQLQ-C30.ConclusionInsummary,thefindingsfromthispreliminaryvalidationstudyindicatesthattheIranianversionoftheHADSisareliableandvalidmeasureofanxietyanddepressionandnowitcanbeusedinstudiesofqualityoflifeincancerpatients.Thenextstepistousethequestionnaireindifferentcancerpatientsorotherchronicdiseasepopulations. 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HealthQualLifeOutcomes1,14(2003).https://doi.org/10.1186/1477-7525-1-14DownloadcitationReceived:10February2003Accepted:28April2003Published:28April2003DOI:https://doi.org/10.1186/1477-7525-1-14SharethisarticleAnyoneyousharethefollowinglinkwithwillbeabletoreadthiscontent:GetshareablelinkSorry,ashareablelinkisnotcurrentlyavailableforthisarticle.Copytoclipboard ProvidedbytheSpringerNatureSharedItcontent-sharinginitiative KeywordsBreastCancerPatientEmotionalFunctioningGlobalQualityDepressionSubscaleEarlyStageBreastCancerPatient DownloadPDF Advertisement HealthandQualityofLifeOutcomes ISSN:1477-7525 Contactus Submissionenquiries:[email protected] Generalenquiries:[email protected]